The Lancet Series on Breastfeeding 2023

AIMS Journal, 2023, Vol 35, No 2

By Laura Scarlett

“Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.” The Lancet Series on Breastfeeding, 2023.

The World Health Organisation (WHO) has an ambitious target: for 70% of mothers to exclusively breastfeed for the first 6 months of life by 2030^[1]. Currently, in the UK, less than 1% achieve this goal, despite an initiation rate of over 80%. Eight out of ten women stop breastfeeding before they are ready^[2], self-reporting insufficient milk supply as the most common reason for cessation. This is reflective of breastfeeding results from around the world, and, with some urgency, The Lancet Series on Breastfeeding 2023,^[3] explores the forces that influence these low rates.

The series, released in February 2023, is a collection of three papers: global systematic studies of data released between 2016-2023, which highlight the benefits of breastfeeding; a review of the social and structural barriers which prevent these benefits from being realised; and an examination of the predatory and manipulative strategies used by commercial milk formula (CMF) companies to circumvent and often violate the WHO Code of Marketing Breastmilk Substitutes 1981^[4] (known as The Code), in order to undermine and compete commercially against the physiological process of breastfeeding.

The series, particularly the third paper, crucially explores the neo-liberal ideals of individualism rather than collectivism,^[5] and how they have penetrated the family unit, leading to social isolation and an unfair pressure on mothers to “succeed” at breastfeeding, rather than an emphasis on the collective social responsibility to support breastfeeding mothers. These factors, coupled with a chronic lack of recognition for and remuneration of women’s unpaid work, have huge implications for the sustainability of breastfeeding. The failure to recognise the benefits of breastfeeding and provide the structural and social support required to facilitate higher rates of breastfeeding, has impacted the human rights of women and children, the motherhood pay penalty^[6], and global and environmental health.

In its 2016 series on breastfeeding,^[7] on which this series is built, The Lancet estimated that exclusive breastfeeding would prevent 823,000 annual deaths in children younger than five years worldwide, as well as 20,000 annual maternal deaths from breast cancer^[8]. Yet fewer than half of newborns are put to the breast within the first hour of life, with 1 in 3 receiving pre-lactal (foods given to newborns before breastfeeding) feeds. This practice leads to an increased risk of cessation of breastfeeding and poor health outcomes. The Lancet does not blame mothers or children for this shortfall, but instead the commercial milk formula companies and their rapacious commercial practices, which have captured women, families, communities, health practitioners and governments at a global level.

Over decades, since 1865, these companies have exploited women’s insecurities about their ability to feed and satisfy their babies, by pathologising normal infant behaviour such as crying and needing regular feeds, and by portraying “…breastfeeding, and thereby women's bodies, as inherently difficult, unreliable, and inconvenient.”^[9] Commercial milk formula, presented as the magic bullet solution to a range of normal infant behaviours (which don’t need fixing), capitalises on parental uncertainty to exploit “…emotions, aspirations, and scientific information with the aim of reshaping individual, societal, and medical norms and values.”⁹

The series examines how CMF (commercial milk formula) marketing practices are in direct violation of The Code, the only food marketing regulation in the world, as well as at least three of the human rights of women and children, including: the right to access impartial and truthful information; a child’s right to health; and a child’s right to life, survival and development. Over the years, CMF marketing tactics have embedded a distrust of breastfeeding within communities and even health care systems, increasing reliance on CMF and causing profits to soar.

Indeed, the Lancet draws meaningful attention to sales of CMF which have grown by over $50 billion USD in four decades. With profits so large, the CMF industry wealth is equivalent to the 62^nd largest economy in the world. The CMF marketing spend is huge, and growing, accounting for 16.7% of net sales, approximately $627 million USD per year. There are just six CMF companies that dominate the CMF market, with one other huge competitor: breast milk.

While these companies fight for their “share of the stomach” by undermining breastfeeding and falsely presenting CMF as a helpful and equivalent alternative, they also serve to obscure the real barriers to breastfeeding faced by many mothers, which tend to be structural, rather than, as CMF marketing suggests, individual. This message is compounded by neo-liberal public health messaging that, “frames breastfeeding as a matter of individual responsibility and, in particular, women's responsibility alone.”

But how can it be an individual responsibility when breastfeeding has such a meaningful impact on the economy and global health? The Lancet estimates that not breastfeeding contributes to economic losses of US$341.3 billion annually from, “increased health-care costs, reduced cognition of children who are not breastfed, and reduced workforce productivity associated with not breastfeeding.” UNICEF estimates that in the UK alone, the unrealised social and economic benefits of breastfeeding could save the NHS up to £50 million per year.^[10]

And that’s not all: the environmental benefits of breastfeeding are huge, with 6 months of exclusive breastfeeding, saving 95-153kg of C02 per baby compared with formula. According to a study at Imperial College London, if all UK mothers were supported to breastfeed, C02 savings would equate to taking between 50,000 and 77,500 cars off the road each year. ^[11]

With such staggering benefits, The Lancet calls for recognition of the unpaid reproductive labour of women, and meaningful collective action within communities, health systems and governments to protect breastfeeding and breastfeeding mothers. It rejects the idea that breastfeeding is a free or costless activity or lifestyle choice for women, but instead recognises the unpaid labour of women in producing a meaningful, life-saving, food production and nurture and care system, which is beyond replication.

The third paper reports that breast milk production, if monetised, would have a commercial value of $3.6 trillion USD per year, while estimating that if the unpaid work of women were included when measuring national economic performance, it would equate to 20-40% GDP worldwide. It argues that reform is needed to factor these unpaid work burdens into policy making and recommends structural changes to relieve pressure on mothers, including fair maternity leave and pay, to adequately remunerate women for the work they do. This requires meaningful global recognition of the financial, health and environmental benefits of breastfeeding and commitment from governments to promote gender equality and safeguard the rights of women and children. It also calls for countries to implement The Code in meaningful ways to curtail, regulate or even eliminate CMF marketing strategies, while providing funding for health care providers to ensure robust breastfeeding support is prioritised and implemented within healthcare settings and communities.

The series is an unapologetic exposé on the barriers to breastfeeding, with practical recommendations^[12] to support breastfeeding mothers and improve global breastfeeding rates for a healthier and fairer world. While this is by no means the first time a light has been shone on the unethical practices of CMF companies, or the unpaid work of mothers, it is powerful to see it argued so persuasively across three robust, engaging, international papers.

However, for many health care workers and breastfeeding specialists, working at the coal face of perinatal services which have been the victims of swingeing austerity measures and cost-cutting service limitations over the past decade and more, it is hard not to wonder how realistic these series recommendations are. While it’s essential to understand the inner workings of CMF marketing strategies and to consider the unpaid care work of women, including how much breast milk production is worth, it is difficult to see how this insight can reverse the generational damage caused by the collective and systematic betrayal of mothers in the global failure to support breastfeeding.

There are few more emotive topics than how a mother feeds her baby and the feelings of failure and guilt caused by the early cessation of breastfeeding can make any criticism of CMF feel like a personal attack. No loving mother wants to harm her baby; in fact CMF is often deployed to avoid that risk, and in some cases, rightly so. But for those who have been undermined and misinformed by CMF marketing tactics, the reality can be (understandably) hard to accept. However, this series isn’t about the individual women who are navigating the difficult cultural and pragmatic issues surrounding how to feed their babies. It’s about how breastfeeding is prevented by the prioritisation of profit over health and a collective societal and governmental failure to defend the rights of mothers and babies and health of global populations.

The series ultimately looks towards a world where parents and families are supported in the care of their infants, where breastfeeding is robustly promoted, supported and protected at all levels, and in which predatory CMF marketing practices and the systematic undermining of women and children become a memory of the past.

Author Bio: Laura is a birth and postnatal doula, maternity support worker and breastfeeding counsellor in training. She is a mother of two and passionate about supporting women through their transformation into motherhood. All views are her own.